Address for correspondence:
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Address for correspondence:
Address for correspondence:
Address for correspondence:
Piotr Kukla, MD, PhD, Department of Internal Diseases and Cardiology, H. Klimontowicz Hospital, ul. Węgierska 21, 38–300 Gorlice, Poland, e-mail: kukla_piotr@poczta.onet.pl
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Received: 08.11.2010 Accepted:Accepted:Accepted:Accepted:Accepted: 10.03.2011 Copyright © Polskie Towarzystwo Kardiologiczne
The prognostic value of ST−segment elevation in the lead aVR in patients with acute pulmonary embolism
Piotr Kukla
1, Robert Długopolski
2, Ewa Krupa
3, Romana Furtak
4, Ewa Mirek−Bryniarska
5, Marek Jastrzębski
6, Piotr Wańczura
7, Leszek Bryniarski
61Department of Internal Diseases and Cardiology, H. Klimontowicz Hospital, Gorlice, Poland
2Department of Cardiology, Hospital, Nowy Targ, Poland
3Department of Cardiology, E. Szczeklik Hospital, Tarnow, Poland
4Department of Internal Diseases and Cardiology, John Paul II Hospital, Rzeszow, Poland
5Department of Cardiology, J. Dietl Hospital, Krakow, Poland
61st Department of Cardiology and Hypertension, University Hospital, Krakow, Poland
7Department of Cardiology, Voivod Hospital Nr 2, Rzeszow, Poland
A b s t r a c t
Background: Electrocardiogram (ECG) in patients with acute pulmonary embolism (APE) presents many abnormalities. There are no data concerning prognostic significance of ST-elevation (STE) in lead aVR in patients with APE.
Aim: To assess the prevalence of STE in aVR in patients with APE and its correlation with clinical course as well as other ECG parameters recorded at admission.
Methods: The retrospective analysis of 293 patients with APE diagnosed according to the ESC guidelines (182 females, 111 males, mean age 65.4 ± 15.5 years).
Results: The STE in lead aVR was observed in 133 (45.3%) patients. In comparison with patients without STE, patients with STE in lead aVR (STaVR[+]) had significantly more often systolic blood pressure < 90 mm Hg on admission (27% vs 10%, p < 0.001) and positive troponin level (64.8% vs 27.9%, p < 0.001). Thrombolytic therapy (14.3% vs 5.6%, p = 0.009) and catecholamines (29.3% vs 7.5%, p < 0.001) were more frequently used in patients with STaVR(+). The overall mortality (16.5% vs 6.9%, p = 0.009) and complication rates during hospitalisation (38.3% vs 12.5%, p < 0.001) were significantly higher in patients with STaVR(+). The STaVR(+) was significantly more frequent in patients with negative T-waves in inferior leads (59.4% vs 39.4%, p < 0.001), STE in lead III (24% vs 5.6%, p < 0.001), STE in lead V1 (46.6% vs 7.5%, p < 0.001), ST depression in lead V4–V6 (48.9% vs 7.5%, p < 0.001), right bundle branch block (15.8% vs 8.1%, p = 0.04), QR sign in lead V1 (18% vs 6.2%, p < 0.001) and SI-QIII-TIII(46.6% vs 21.2%, p < 0.001).
Conclusions: The presence of STE in lead aVR in patients with APE is associated with poor prognosis. The presence of STE in lead aVR could be an easily obtainable and noninvasive ECG parameter, helpful in risk stratification of patients with APE.
Key words: acute pulmonary embolism, lead aVR, ECG, mortality
Kardiol Pol 2011; 69, 7: 649–654
INTRODUCTION
Until recently, ST-segment changes in lead aVR have rarely been included in the electrocardiogram (ECG) analysis. The- re was even a common belief that ECG consists of 11 leads and that lead aVR is only a scarcely usable ”addition” [1, 2].
However, over the last years it has been demonstrated that ST changes in lead aVR occur in acute coronary syndromes and that they are clinically and prognostically relevant. The ST-segment elevation in lead aVR can also be useful in diffe- rentiation of supraventricular arrhythmias, wide QRS com- plex tachycardias and in risk stratification in patients with Bru- gada syndrome [3–5].
Recently published studies showed that the presence of ST-segment elevation in lead aVR is related to the clinical course of non-ST-elevation myocardial infarction (NSTEMI) [6, 7]. The usefulness of the assessment of ST-segment eleva- tion in lead aVR in patients with 3-vessel disease or left main disease was confirmed [8, 9].
The ST-segment changes in lead aVR can be useful in the identification of infarct-related artery in STEMI patients [10–12]. Japanese investigators demonstrated that the extent of ST-segment depression in lead aVR in the course of inferior wall STEMI correlates with impaired reperfusion despite pri- mary intervention [13]. Similarly, it has been demonstrated that ST-depression in lead aVR in patients with NSTEMI of the an- terior wall undergoing primary intervention, was more frequ- ently related to in-hospital heart failure and greater extent of left ventricular dysfunction despite successful reperfusion [14].
In patients with acute pulmonary embolism (APE), mul- tiple ECG abnormalities can be found [15], however, little is known on the prognostic value of ST-elevation in lead aVR.
The aim of the study was to assess the prevalence of ST-elevation in lead aVR in APE and to evaluate its relation- ship with clinical presentation and clinical course of APE, myo- cardial injury markers and other ECG changes.
METHODS Study group
The study group consisted of 293 consecutive patients (182 wo- men, 111 men) aged 17–89 years, hospitalised between 2006 and 2009 with the diagnosis of APE. Mean duration of hospitalisation was 15 days (longest: 46 days, mean 15.1 ±
± 8.7 days). Demographic and clinical data are presented in Table 1.
The diagnosis of pulmonary embolism
Acute pulmonary embolism was diagnosed based on the fol- lowing diagnostic tests: computed tomography 253 (86.3%) patients, echocardiography — 24 (8.2%) patients (including 16 patients with right ventricular overload and shock and 8 patients in whom embolic material was directly visualised in right heart chambers), doppler ultrasound of the proximal
deep veins of the lower extremity — 9 (3%) patients, scinti- graphy — 5 (1.7%) patients and autopsy — 2 (0.7%) patients.
Electrocardiographic study
In all patients 12-lead ECG was performed at 25 mm/s or 50 mm/s speed and amplitude of 10 mm/mV. First available ECG of each patient performed on admission was analysed in terms of ST-segment elevation in lead aVR. The ST-seg- ment elevation in aVR was diagnosed when the J point was elevated ≥ 1 mm above the isoelectric line. The following additional ECG features were analysed: (1) supraventricular arrhythmia occurrence (atrial fibrillation); (2) QRS axis;
(3) P-pulmonale, if P wave amplitude was > 0.25 mV in at least one of the inferior limb leads (i.e. leads II, III or aVF);
(4) complete right bundle branch block (RBBB); (5) McGinne- -White sign (SI-QIII-TIII); (6) negative T-waves in leads III and aVF; (7) negative T-waves in leads V2–V4; (8) ST-segment de- pression in leads V4–V6; (9) ST-segment elevation in leads III, V1 and V2–V4; (10) Q(q)R complex in lead V1; (11) dextrogyria, when amplitude ratio R/S £ 1 in lead V5; (12) low voltage of the QRS (< 5 mm) in limb leads.
Acute pulmonary embolism clinical course analysis
In-hospital observation included the rate of the following com- plications: all cause mortality, cardiac arrest, inotropic drug administration, cardiogenic shock and ventilatory support.
Statistical analysis
Continuous variables with normal distribution are presented as mean ± SD. Categorical variables were analysed with c2 test (for small groups Yates correction was applied). A p-value of < 0.05 (two-tailed) was consiedered statistically significant.
Table 1.
Table 1.Table 1.
Table 1.
Table 1. Demographic and clinical characteristics of the study group
Age [years] 65.4 ± 15.5
Women/men 182/111 (62.1%/37.9%)
Immobilisation 85 (29.1%)
Thrombophlebitis of the lower extremity 136 (46.6%)
Malignancy 22 (7.5%)
HRT/anticonception 8 (2.7%)
Heart failure NYHA class III/IV 36 (12.3%) Chronic obstructive pulmonary disease 24 (8.2%)
Unexplained fever 36 (12.2%)
High risk group 73 (24.9%)
Chest pain 132 (45.0%)
Syncope 85 (29.0%)
HRT — hormonal replacement therapy; NYHA — New York Heart Association
Statistical calculations were performed with STATISTICA 6.1 PL (StatSoft Inc.).
RESULTS
The ST-segment elevation in lead aVR was observed in 133 (45.3%) patients. In these patients, systolic blood pressure (SBP) < 90 mm Hg on admission and elevated troponin con- centrations were significantly more frequent than in the re- maining patients. Moreover, fibrinolysis and positive inotro- pic agents were significantly more frequently used in these patients. In high risk APE patients, the ST-elevation in lead aVR was found significantly more frequently than in patients with non-high risk APE. Overall in-hospital mortality and the number of pre-discharge complications were significantly hi-
gher in patients with ST-elevation in lead aVR than in the remaining patients (Table 2).
The sensitivity and specificity of the ST-elevation in lead aVR as a predictor of mortality were 66.7% and 57.3%, re- spectively. The respective positive and negative predictive values were 16.6% and 93.1%. In non-high risk patients, sen- sitivity and specificity for the prediction of mortality were 44%
and 64%, respectively, whereas the positive and negative pre- dictive values (PPV, NPV) were 5% and 96.4%.
The ST-segment elevation in lead aVR was more frequ- ently seen in patients with inferior leads T-wave inversion, with lead III ST-elevation, V1 ST-elevation, ST-depression in leads V4–V6, RBBB, the QR sign in lead V1 and in patients with SI-QIII-TIII sign (Table 3).
Table 3.
Table 3.
Table 3.
Table 3.
Table 3. Electrocardiographic changes — prevalence in the whole study group and comparison between patients with or without ST-elevation in aVR
All patients STaVR(+) STaVR(–) P
Atrial fibrillation 62 (21.1%) 34 (25.6%) 28 (17.5%) NS
Left axis deviation 140 (47.8%) 60 (45.1%) 80 (50%) NS
Negative T-wave inferior 142 (48.5%) 79 (59.4%) 63 (39.4%) < 0.001
Negative T-wave anterior 117 (39.9%) 62 (46.6%) 55 (34.8%) NS
ST-elevation III 41 (13.9%) 32 (24%) 9 (5.6%) < 0.001
ST-elevation V1 74 (25.6%) 62 (46.6%) 12 (7.5%) < 0.001
ST-depression V4–V6 77 (26.3%) 65 (48.9%) 12 (7.5%) < 0.001
Right bundle branch block 34 (11.6%) 21 (15.8%) 13 (8.1%) 0.04
QR sign V1 34 (11.6%) 24 (18%) 10 (6.2%) < 0.001
SI-QIII-TIII sign 96 (32.8%) 62 (46.6%) 34 (21.2%) < 0.001
Dextrogyria 181 (61.8%) 89 (66.9%) 92 (57.5%) NS
P pulmonale 43 (14.7%) 24 (18%) 19 (11.9%) NS
Low voltage QRS 24 (8.2%) 13 (9.8%) 11 (6.9%) NS
Abbreviations as in Table 2 Table 2.
Table 2.
Table 2.
Table 2.
Table 2. The prevalence of investigated parameters In the whole study group and comparison between patients with or without ST-elevation in aVR
All; n = 293 STaVR(+); n = 133 STaVR(–); n = 160 P
Chest pain 132 (45%) 53 (39.9%) 79 (49.4%) NS
Syncope 85 (29%) 40 (30%) 45 (28.1%) NS
SBP < 90 mmHg 52 (17.8%) 36 (27%) 16 (10%) < 0.001
RV ECHO > 30 mm 183 (62.4%) 79 (59.4%) 104 (65%) NS
cTnT(+)* 102/227* 68/105 (64.8%) 34/122 (27.9%) < 0.001
Thrombolysis 28 (9.5%) 19 (14.3%) 9 (5.6%) 0.009
Cardiac arrest 35 (12%) 23 (17.3%) 12 (7.5%) 0.01
Inotropic drugs 51 (17.4%) 39 (29.3%) 12 (7.5%) < 0.001
Death 33 (11.2%) 22 (16.5%) 11 (6.9%) 0.009
Complications 71 (24.2%) 51 (38.3%) 20 (12.5%) < 0.001
High risk group 73 (24.9%) 53 (39.8%) 20 (12.5%) < 0.001
STaVR(+) — ST-elevation in lead aVR; STaVR(–) — no ST-elevation in lead aVR; SBP < 90 mm Hg — systolic blood pressure on admission < 90 mm Hg, RV ECHO — right ventricular dimension on echocardiography; cTnT(+) — elevated troponin concentration*, only patients in whom troponin was measured were included (n = 227)
In patients with ST-elevation in lead aVR who also had such ECG findings as RBBB, QR in lead V1, negative T-waves in leads III and aVF, ST-elevation in leads III and V1 or SI-QIII-TIII sign, the overall in-hospital mortality was significantly higher than in the remaining patients (Fig. 1).
DISCUSSION
The diagnosis of APE is still difficult and its clinical course frequently insidious [15]. The ECG is one of the first diagno- stic tests performed in patients with chest pain or dyspnea on admission. It should be emphasised, that there are no sensiti- ve or specific ECG signs of APE. The ECG can not be used for APE diagnosis, but it can be helpful in differential diagnosis of other acute cardiovascular conditions.
Currently, ECG is not taken into account in the APE risk stratification. Toosi et al. [16] developed a 21-point ECG eva- luation score and demonstrated that score ≥ 3 allows for pre- diction of complicated clinical course and all-cause mortality with a sensitivity of 58% and 59%, specificity of 60% and 58%
and with NPV of 89 and 95%, respectively. The ECG score of
≥ 3 allowed for prediction of right ventricular dysfunction (RVD) with 76% sensitivity, 82% specificity and PPV and NPV of 76% and 86%, respectively [16].
Punukollu et al. [17] found that ECG can be helpful in RVD prediction. In their study, McGinne-White sign (SI-QIII-TIII) and negative T-waves in leads V1–V3 were observed significantly more frequently in APE patients with RVD than in patients with prese- rved RV function [17]. The ECG score was then used for predic-
tion of perfusion defects. Iles et al. [18] demonstrated that ECG score of ≥ 3 predicted > 50% perfusion defect on scintigraphy with a sensitivity of 70% and a specificity of 59%. In a study of Kostrubiec et al. [19], the ECG score of ≥ 3 had 92% sensiti- vity and NPV of 97% in the prediction of RVD. Also, the score of
≥ 3 had sensitivity and NPV of 75% and 92%, respectively, in the prediction of complicated clinical course. Hence, it seems that ECG evaluation conveys relevant information and can add to risk stratification in APE patients.
There is one abstract available in the literature regarding the prognositic significance of ST-segment elevation in lead aVR in APE [20]. Hoechtl et al. [20] reported ST-segment ele- vation in lead aVR in 35% of 396 APE patients. In our study, ST-segment elevation in lead aVR was observed in 133 (45%) patients. In the study by Hoechtl et al. [20], ST-segment ele- vation in lead aVR was related to more unfavourable clinical outcome of APE. These patients significantly more frequently presented with syncope, tachycardia of > 100 bpm, SBP of
< 90 mm Hg on admission, signs of RVD on echocardiogra- phy and higher troponin concentrations.
In our study, 27% of the patients with ST-elevation in lead aVR were haemodynamically unstable on admission (SBP < 90 mm Hg), and 64.8% of these patients had eleva- ted troponins. In the study by Hoechtl et al. [20], patients with ST-segment elevation in lead aVR significantly more fre- quently received thrombolysis (29% patients). Similarly, in our study patients with ST-segment elevation in lead aVR signifi- cantly more frequently required intensified therapy, as more Figure 1.
Figure 1.
Figure 1.
Figure 1.
Figure 1. Comparison of in-hospital mortality rates in patients with ST-segment elevation in lead aVR in combination with other ECG parameters (green bars) and in patients without these ECG abnormalities (gray bars); RBBB — right bundle branch block, negT-ant — negative T-wave in leads V2–V4; negT-inf — negative T-wave in leads III and aVF, ST depV4–V6 — ST-depression in leads V4–V6; STE lead III/V1 — ST-elevation in lead III/V1
of these patients received thrombolysis (14.3% vs 5.6%) and inotropic drugs (29.3% vs 7.5%)
Hoechtl et al. [20] observed a somewhat higher mortali- ty (albeit non-significant) in patients with ST-segment eleva- tion in lead aVR than in the remaining patients (10.3% vs 5.4%). In our study, clinical outcomes were worse: mortality (16.5% vs 6.9%) and in-hospital complication rates (38.3%
vs 12.5%) were significantly higher in patients with ST-seg- ment elevation in lead aVR compared to patients without such ECG finding. In patients with high risk of death, ST- -segment elevation in lead aVR was significantly more frequ- ent (39.8% vs 12.5%).
The ST-segment elevation in lead aVR in the setting of APE can be related to acute right ventricular overload, tran- sient hypoxaemia resulting from impaired coronary blood flow and increased oxygen demand [21].
In our study, the in-hospital mortality rate was doubled in patients with ST-segment elevation in lead aVR when it was combined with RBBB, QR in lead V1, negative T-waves in leads V2–V4 or III and aVF, ST-elevation in III and V1, SI-QIII-TIII sign or dextrogyria, in comparison to patients without the combination of such ECG findings.
It seems that ECG in APE patients can be of value in risk stratification. The ECG analysis and application of several pro- posed ECG scoring systems conveys significant information.
However, from practical point of view, it can be time-consu- ming, hence the use of those scoring systems in everyday cli- nical practice is limited. On the other hand, the analysis of the ECG in terms of ST-segment elevation in lead aVR provi- des relevant information. The ST-segment elevation in lead aVR has limited sensitivity and specificity, but high NPV for mortality (93%). Hence, the lack of ST-segment elevation in lead aVR is related to good prognosis. Our study shows that ST-segment elevation in lead aVR predicts unfavourable out- come: increased all-cause mortality and higher in-hospital complication rates.
CONCLUSIONS
1. The ST-segment elevation in lead aVR in patients with APE is related to unfavourable outcome.
2. The ST-segment elevation in lead aVR in patients with APE can be a valuable, non-invasive and easily obtainable mar- ker, helpful in risk stratification of patients with APE.
Conflict of interest: none declared References
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Znaczenie prognostyczne uniesienia odcinka ST w odprowadzeniu aVR
u chorych z ostrą zatorowością płucną
Piotr Kukla
1, Robert Długopolski
2, Ewa Krupa
3, Romana Furtak
4, Ewa Mirek−Bryniarska
5, Marek Jastrzębski
6, Piotr Wańczura
7, Leszek Bryniarski
61Oddział Internistyczno-Kardiologiczny, Szpital im. H. Klimontowicza, Gorlice
2Oddział Kardiologii, Szpital, Nowy Targ
3Oddział Kardiologii, Szpital im. E. Szczeklika, Tarnów
4Oddział Kardiologii i Chorób Wewnętrznych, Szpital im. Jana Pawła II, Rzeszów
5Oddział Kardiologii, Szpital im. J. Dietla, Kraków
6I Klinika Kardiologii i Nadciśnienia Tętniczego, Szpital Uniwersytecki, Kraków
7Klinika Kardiologii, Szpital Nr 2, Rzeszów
S t r e s z c z e n i e
Wstęp: W EKG chorych z ostrym zatorem tętnicy płucnej można stwierdzić wiele różnych nieprawidłowości. Brakuje donie- sień dotyczących znaczenia rokowniczego uniesienia odcinka ST w odprowadzeniu aVR.
Cel: Celem pracy była ocena częstości występowania uniesienia odcinka ST w odprowadzeniu aVR w ostrym zatorze tętnicy płucnej oraz związku tego zjawiska z prezentacją kliniczną tej choroby w chwili przyjęcia do szpitala, przebiegiem klinicz- nym, obecnością markerów uszkodzenia mięśnia sercowego i występowaniem innych zmian w EKG.
Metody: Do badania włączono 293 chorych (182 kobiety, 111 mężczyzn) w wieku 17–89 lat (średni wiek 65,4 ± 15,5 roku).
Wyniki: Uniesienie odcinka ST w odprowadzeniu aVR stwierdzono u 133 (45,3%) chorych. U pacjentów z uniesieniem odcinka ST w odprowadzeniu aVR [STaVR(+)] w porównaniu z osobami bez uniesienia odcinka ST znamiennie częściej obserwowano skurczowe ciśnienie tętnicze < 90 mm Hg przy przyjęciu (27% v. 10%; p < 0,001), podwyższone stężenie troponiny (64,8% v. 27,9%; p < 0,001). U terapii chorych z STaVR(+) znamiennie częściej stosowano fibrynolizę (14,3%
v. 5,6%; p = 0,009) i aminy katecholowe (29,3% v. 7,5%; p < 0,001). Śmiertelność całkowita (16,5% v. 6,9%; p = 0,009) i liczba powikłań w trakcie hospitalizacji (38,3% v. 12,5%; p < 0,001) była znamiennie większa u pacjentów z STaVR(+).
STaVR(+) znamiennie częściej obserwowano u chorych z ujemnymi załamkami T w odprowadzeniach znad ściany dolnej (59,4% v. 39,4%; p < 0,001), uniesieniem odcinka ST w odprowadzeniu III (24% v. 5,6%; p < 0,001), uniesieniem odcinka ST w odprowadzeniu V1 (46,6% v. 7,5%; p < 0,001), obniżeniem odcinka ST w odprowadzeniach V4–V6 (48,9% v. 7,5%;
p < 0,001), blokiem prawej odnogi pęczka Hisa (15,8% v. 8,1%; p = 0,04), objawem QR w odprowadzeniu V1 (18%
v. 6,2%; p < 0,001) oraz objawem SI-QIII-TIII(46,6% v. 21,2%; p < 0,001).
Wnioski: Obecność STaVR(+) u chorych z ostrym zatorem tętnicy płucnej wiąże się z niekorzystnym rokowaniem i może być nieinwazyjnym oraz łatwo dostępnym markerem pomocnym w stratyfikacji ryzyka chorych z ostrym zatorem tętnicy płucnej.
Słowa kluczowe: zator tętnicy płucnej, odprowadzenie aVR, EKG, śmiertelność
Kardiol Pol 2011; 69, 7: 649–654
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dr n. med. Piotr Kukla, Oddział Internistyczno-Kardiologiczny, Szpital Specjalistyczn, 38-300 Gorlice, ul. Węgierska 21, e-mail: kukla_piotr@poczta.onet.pl Praca wpłynęła:
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Praca wpłynęła: 08.11.2010 r. Zaakceptowana do druku:Zaakceptowana do druku:Zaakceptowana do druku:Zaakceptowana do druku:Zaakceptowana do druku: 10.03.2011 r.
